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Abnormal
Uterine
Bleeding
Causes, Evaluation and Treatment

PALMCOEIN
Introduced by FIGO
Supported by ACOG
Create consistency in research
Help define roles in diagnosis and
treatment
Help standardize the approach

Termsabandonedinthe
FIGOnomenclaturesystem

Dysfunctional uterine bleeding

Epimenorrhagia
Epimenorrhea
Functional uterine bleeding
Hypermenorrhea
Hypomenorrhea
Menometrorrhagia
Menorrhagia (all usages: essential menorrhagia, idiopathic menorrhagia,
primary menorrhagia, functional menorrhagia, ovulatory menorrhagia,
anovulatory menorrhagia)
Metrorrhagia
Metropathica hemorrhagica
Oligomenorrhea
Polymenorrhagia
Polymenorrhea
Uterine hemorrhage

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Clinicaldimensionsofmenstruation
andmenstrualcycle

Frequencyofmenses,d

Frequent

<24

Normal

2438

Infrequent

>38

Clinicaldimensionsofmenstruationand
menstrualcycle

Regularityofmenses:
cycletocyclevariation
over12months,d

Absent

Nobleeding

Regular

Variation 220

Irregular

Variation>20

Clinicaldimensionsofmenstruationand
menstrualcycle

Durationofflow,d

Prolonged

>8.0

Normal

4.58.0

Shortened

<4.5

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Clinicaldimensionsofmenstruationand
menstrualcycle

Volumeofmonthly
bloodloss,mL

Heavy

>80

Normal

580

Light

<5

COEIN
Structural

Polyp
Adenomyosis
Leiomyoma
Malignancy

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PALM
Nonstructural

Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified

PALMCOEIN
No place for dysfunctional uterine bleeding

DUB

PALMCOEIN

PALM are most common

Polyp
Adenomyosis
Leiomyomas
Malignancy

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Workup

History
Use descriptive scheme
Pain
Family history of AUB or bleeding
disorder
o 20% will have an underlying bleeding
disorder
Meds
Herbs

Meds

Warfarin
Heparin
NSAID
OCPs

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Herbs
Ginko
Ginseng
Motherwort

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Exam
Overweight
PCOS signs
o Acne
o Hirsutism

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Exam
Overweight
PCOS signs
o Acne
o Hirsutism

Thyroid nodule

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Exam

Overweight
PCOS signs
o Acne
o Hirsutism
Thyroid nodule

Insulin resistance
o Acanthosis nigricans on neck

Exam

Overweight
PCOS signs
o Acne
o Hirsutism
Thyroid nodule
Insulin resistance
o Acanthosis nigricans on neck

Signs of bleeding disorder

o Petechiae
o Ecchymoses
o Skin pallor
o Swollen joints

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Pelvic
Cervical or vaginal lesions
o Biospy?
Uterine size
Uterine contour

10

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Lab
UPT
CBC
Screening for bleeding disorders (when
indicated)
TSH
Chlamydia

Imagingetc

US
Saline infusion US
MRI
Hysteroscopy
EMB

AgeBreakdown
13-18
o Hypothalamic-Pituitary-Ovarian
access immature
o OCP
o Pregnancy
o Pelvic infection
o Coagulopathies
o Tumor

11

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AgeBreakdown
19-39
o Pregnancy
o Polyp
o Leiomyoma
o Anovulation (PCOS)
o Hormonal contraceptives
o Hyperplasia
o Less commonly cancer

AgeBreakdown
40
o Anovulatory bleeding
o Hyperplasia
o Cancer
o Endometrial atrophy
o Leiomyoma

Imaging
No clear advantage in initial
workup
TVUS if persistent
Endometrial thickness in
premenopausal patient is not
helpful

12

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Imaging
TVUS great for myometrial evaluation
SIS great for evaluation of endometrial cavity
46% have something abnormal about the cavity
3D some evidence that it helps determine the
depth of myometrial invasion of leiomyoma
MRI weigh cost and benefits
o Prior to myomectomy?
o Prior to UAE
o HIFU

Biopsy
Over 45 - definitely
Younger
o If unopposed estrogen
PCOS
Obese
o Failed medical management
o Persistent AUB
Positive predicative value better than negative
predicative value

Biopsy
Only an endpoint if
oCancer
oAtypical hyperplasia

13

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AUBP
Polyp
Hysteroscopy

AUBA
Adenomyosis
MRI
US
o Heterogeneous
o Myometrial cysts
o Asymmetrical myometrial thickness
o Subendometrial echogenic linear
striations

14

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AUBE

Abnormal prostaglandin synthesis

Prostaglandin receptor upregulation
Increased fibrinolytic activity
Increase tissue plasminogen activity

15

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Rx
Low risk patients
o Trial of meds
NSAIDs
Progestins
OCPs
Levonorgestrel IUD
Tranexamic acid

ProbabilityofHysterectomyAfter
EndometrialAblation
Mindyn K.Longinotti,MD,GavinF.
Jacobson,MD, YunYiHung,PhD,andLee
A.Learman,MD,PhD

N ~ 4000
Kaiser patients
Did not include laser or Cryo
26% went to hysterectomy
Eight year follow up

16

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Fig.1

Copyright 2012 Obstetrics & Gynecology. Published by Lippincott Williams & Wilkins.

49

Leiomyomas
Hysterectomy
OR

17

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Leiomyomas

Contraceptive steroids
NSAIDs
GnRH agonists
Aromatase inhibitors
Progesterone modulators

Leiomyomas
Myomectomy
o Open
o Laparoscopy
o Robot
o Hysteroscopy
UAE
mrHIFU

Caveats
Preop GnRH agonist
GnRH antagonist
o No steroid flare
Vasopressin

18

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Myomectomy
CS??????

Myomectomy
CS??????
No clinical trials
1 rupture in 750 pooled laparoscopic
myomectomies
Maintain a high index of suspicion

Myomectomy
Help with future conception?
Myomas present in 5-10% of infertility
patients
Sole identifiable factor in 1-2.4%
IVF patients with submucous myomas
seem to benefit

19

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Myomectomy
Recurrence
Adhesions

UAE
Ovarian failure
Increased risk with age
12% placentation problems
o Previa
o Accreta

mrHIFU
Studies comparing to
myomectomy ongoing

20

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Highintensityfocused
ultrasoundtreatmenton70
uterinefibroids:efficacyand
safety
Mayinuer Niyazi,Haiyan Sun,Yan
Li,Shuhua Huang,WeiWang
Gynaecology,PeoplesHospitalof
XinjiangVvgur Autonomous
Region,China

mrHIFU
Actually 70 patients
FDA approved
Trial going on in patients desiring future
pregnancy
Myomectomy is comparison group
Results may be a year or more

21

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ExperimentalTherapy

FIGURE2Transvaginalsonogramguidanceofaneedleinsertionintothefibroid <ce:italic> Arrows</ce:italic>marktheneedle

pathway.Theiceballisgeneratedfromthetipbackwardandextendsbeyondthetipbyonlyapproximately 23mm.Ther...

MotyPansky,BryanD.Cowan,MayaFrank,HarrietteL.Hampton,StephenZimberg
Laparoscopicallyassisteduterinefibroidcryoablation
AmericanJournalofObstetricsandGynecologyVolume201,Issue62009571.e1 571.e7
http://dx.doi.org/10.1016/j.ajog.2009.06.028

22

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FIGURE1Laparoscopicvisualization ofcryoandthermalneedlesLaparoscopicvisualization ofcryoandthermalneedles(17 g,

IceRod;GalilMedical, Yokneam,Israel)insertedintoafibroid. Eachneedleismarkedat1cmlengths.Theneedlesare...

MotyPansky,BryanD.Cowan,MayaFrank,HarrietteL.Hampton,StephenZimberg
Laparoscopicallyassisteduterinefibroidcryoablation
AmericanJournalofObstetricsandGynecologyVolume201,Issue62009571.e1 571.e7
http://dx.doi.org/10.1016/j.ajog.2009.06.028

23

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24

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FIGURE3Transvaginalvisualization oftheiceballTransvaginalvisualization oftheiceballgeneratedfromimagesin<ce:cross

refrefid=fig2> Figure2</ce:crossref>.Thefrontedgeoftheiceballisdemarcated,butthebackedgeisnot...

MotyPansky,BryanD.Cowan,MayaFrank,HarrietteL.Hampton,StephenZimberg
Laparoscopicallyassisteduterinefibroidcryoablation
AmericanJournalofObstetricsandGynecologyVolume201,Issue62009571.e1 571.e7
http://dx.doi.org/10.1016/j.ajog.2009.06.028

25

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26

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Prevalence

27